Intro to STM Lecture Flashcards
Manual Therapy: Still
Osteopathy, abnormal structure
Manual Therapy: Cyriax
Musculoskeletal diagnosis
Manual Therapy: Mennell
Joint mobilization and massage
Manual Therapy: Katenborn and Maitland
joint mobilization
Bodywork & Massage
Traditional Swedish Massage Connective Tissue Massage Structural Integration (Rolf) Manual and movement - trigger paint therapy (travell) - shiatsu (acupuncture points) - reflexology - trager (oscillations) - therapeutic "touch" and Reiki
Connective Tissue Cells
- fibroblasts and fibrocytes
- epithelial cells
- macrophages, neutrophils
- mast cells (release histamines)
- plasma cell proteins
Connective Tissue Extracellular Matrix
Fibers - collagen (type I): loose and dense - elastin - reticulin Ground substance - viscous gel-like medium - H20 -GAGs - suspends collagen fibers
Name 3 types of connective tissue
dense regular
dense irregular
loose irregular
Which type of connective tissue is most difficult to redirect? how can it be done?
dense regular connective tissue.
perpendicular friction to break up unwanted fibers
How soon can you start soft tissue mobilization to produce normal collagen remolding?
Not day 1 –> P.R.I.C.E.
On day 2-4 –> proliferation stage may have begun
What type of connective tissue are ligaments and tendon? What are its characteristics?
Dense Regular
Dense parallel collagen fibers
Proportionally less ground substance
Not highly vascular.
What type of connective tissue are joint capsules, dermis, aponeuroses, high-stress fascial sheaths (ie lumbodorsal fascia?) What are its characteristics?
Dense Irregular
Multidirectional collagen fibers
Resists multidirectional stressers
What type of connective tissue is superficial fascia, muscle and nerve sheaths, internal supportive network?What are its characteristics?
Loos Irregular
Sparse, multidirectional fibers
more elastin and ground substance
viscoelastic properties
most likely affected by external forces
What is fibrosis?
What causes fibrosis?
- excessive connective tissue formation (cross linking)
- stimulated by low-grade irritation (overuse/postural stress/ movement dysfunction)
-involves a larger tissue than mere adhesions
(ie restriction in abdomen can restrict shoulder flexion) - impedes structure and function of healing and neighboring tissue
- progresses with time immobilized
- fibrosis can spread to neighboring tissues
What is Stage I of connective tissue repair?
Time frame?
Events?
Relevance to STM?
Inflammation
0-48 hours +
Events:
homeostasis
inflammation
phagocytosis and leukocytosis
Relevance:
STM may disrupt homeostasis
What is Stage II of connective tissue repair?
Proliferation
2-4 days - 2 to 3 weeks.
Events: Re-epithelialization Granulatoin and vascularization Collagen synthesis and fibroplasia Contraction of the defect/wound
Relevance:
STM may disrupt contracture and stimulate increased collagen synthesis
What is Stage III of connective tissue repair?
Remodeling
3 weeks to 12 months
Events:
collagen lysis and synthesis
fiber reorientation
scar maturation continues >1 year
Relevance:
Tensile forces affect new fiber orientation
Adhesions inhibit fiber reorientation
Scar is weaker than skin
Effects of Immobilizatoin on connective tissue?
- adhesions, fibrous infiltrate, and fibrous development
- loss of ground substance
- decrease mobility (longer immobilization, longer recovery time)
Effects of immobilization on muscle?
- sarcomere loss (not likely to cause adaptive shortening)
- fatty intrusion and fibrosis
- cross bridge adhesion (more likely to be the cause)
- affects neighbor muscles in parallel and series
Parasympathetic response to STM
- reduce depression and anxiety
- reduce related measures: BP, HR, RR, lactates, pain
Evidence:
- decreased depression in 17 RTCs
- RTC reflexology decreases anxiety in CA pts
- RTC DECREASES SHORT TERM ANXIETY IN POST-OP PATIENTS
- decreases anxiety, HR, cortisol in psych in-pts
What are the physiological effects of STM?
1) increase circulation, decrease edema & lymphedema
2) parasympathetic response, promote relaxation, decrease anxiety
3) analgesia, decrease pain and discomfort
4) metabolism
5) increase connective tissue mobility or length; prevent fibrosis
6) function
What’s a measurable outcome for increase circulation, decrease edema & lymphedema?
increased blood flow, skin temp, tcO2; decreased girth
What’s a measurable outcome for parasympathetic response, promote relaxation, decrease anxiety?
decreased HR, BP, RR, anxiety medication
What’s a measurable outcome for analgesia, decrease pain and discomfor?
VAS, pain scales, pressure tolerance, analgesic use
What’s a measurable outcome for metabolism?
serum levels, cell counts, spO2
What’s a measurable outcome for increase connective tissue mobility of length; prevent fibrosis?
increased ROM (joint, muscle, fascial mobility), other related functions
What’s ameasurable outcome for function?
functional scales (ie oswestry, FIM, DASH)
Evidence for Analgesic Outcomes
pain relief and/or increased function after massage vs placebo or control
- LBP: decreased LBP after massage vs STM/posture/exercise/placebo and increased function after massage therapy/ STM/posture/exercise vs placebo
- Neck pain: increased function and decreased pain at 4-10 weeks BUT NO CHANGE AT 6 MONTHS VS CONTROL
- Cancer: decreased pain and anxiety IN SHORT TERM AFTER MASSAGE
Evidence for Circulatory Effects
Normal response: reactive hyperemia (capillary dilation)
Increase blood flow vs skin temperature:
- petrissage increases both (cohort)
- petrissage increased temperature but not blood flow (cohort)
- acupressure increases LE and trunk blood flow (case control)
Decrease Edema:
- RETROGRADE MASSAGE and finger wrapping decrease volume
- decreased post exercise swelling
- decrease ankle and pain
May assist increase in lymph motility:
- only support is case study and opinion
Evidence for Analgesic Effects
Proposed processes:
- decreased edema thus pressure on nerve endings (cohort)
- parasympathetic nervous system response (cohort)
- substance P- a CNS neurotransmitter mediating pain (with shiatsu decreased pain and sub P in fibromyalgia)
- Gate control (not really applicable n clinical setting)
- pain and muscle spasm: the pain-spasm cycle
- chemical mediators
Biomechanical Effects
Endorphins (increase in pts with myalgia after CTM)
Serotonin and dopamine:
- increase with decreased pain and depression in LBP pts
- increases with decreased pain in breast CA pts
Cortisol associated with pain and anxiety:
- no change in cortisol in CA
- decreased cortisol in psych in-pts
*cognitive thought can affect cortisol levels
Visceral Effects
May stimulate reflex peristalsis
Cupping (Chest PT) to increase lung secretion
Acupuncture meridians:
- acupuncture increased LE and trunk blood flow in PVD
Head Zones:
Reflexology (decrease pain and anxiety in CA pts)
Immunologic & Metabolic Effects
lymphocyte protection and immune response :
- decreased lymphocyte/helper T loss in HIV+ peds
- increased lymphocyte/helper T in breast CA
Insulin:
- increased insulin/IGF and wt in preterm neonates
Creatine Kinase:
- decreases CK and post exercise soreness but NO INCREASE IN MUSCLE FUNCTION IN NORMALS
Muscle and Connective Tissue Effects of Massage
Theories:
1) Thixotropy: fluid stiffness affects movmeent (like ketchup bottle)
2) Viscoelastic tissue elongation due to stretch:
- no effect on birth perineal trauma
* takes 30 minues to change length of connective tissue. we dont actually do that in the clinic.
3) Neuromuscular relaxation effect
- massage reduces EMG activity AFTER EXERCISE
4) increased fibroblast activity
5) surgical scar reduction?
Gene Expression Effects
Altered expression of fibrin related gene immediately after massage
Altered expression of inflammation-related gene during recovery hours later
- may attenuate inflammatory process and speed healing (1RTC)
Connective Tissue Effects of Myofascial Manipulation
Theories
Fibrous and cross bridge adhesion reduction
- collagen reorientaton (skin thickness changes. decreased adipose)
- bundle orientation (ligaments TFM)
- MAY free neighbor muscles to function
Muscle and Connective Tissue Effects of STM: outcomes and selected evidence
Increased ROM, joint motion; decreased stiffness:
- increased ROM and function in knee OA
- petrissage decreases stiffness in bikers
- increases shoulder ROM and functon
Increase in strength:
- increased grip in CTS
- strength associated with pain
- with friction, decreased fatigue effect on grip strength
Adverse effects?
- muscle soreness
- goose bumps or clamminess (abnormal sympathetic nervous system response)
- unexpected neurological signs (paraesthesia) ==> reposition and continue
- speech or mental status changes
- nausea and/or vomiting
- significant or sudden vital signs changes
- chest, abdominal, or other unexpected pain
Sports Outcomes
- for pitcher’s forearm neuropathy in return to sport
- PRE-SPRINT SPORTS MASSAGE HAD NO POSITIVE EFFECT
PT Indications for STM
- pain
- edema
- impaired ROM
- impaired strength
- postural malalignment
- impaired movement/function
Outcomes in Pediatrics
- reduced pain and itching in pediatric burn patients
- higher mental development scores after massage in low birth weight neonates vs kangaroo carry
Contraindications to STM: general principles
- monitor patient’s respose
- treatment area: general vs regional
- technique: deep/vigorous vs superficial/gentle
- endangerment sites: ie Anterior neck, femoral triangle
- MUST TAKE VITALS AT EVAL
Types of Contraindications
- Acute Inflammation
- Areas of Lost integrity
- communicating pathologies
- cardiac/circulatory disorders
- clotting disorders and anticoagulants
- area of altered sensation
- impaired cognition/communication
Area; depth/technique limited by:
inflamation
regional; all
Area; depth/technique limited by:
areas of lost integrity
regional; deep and or superficial
Area; depth/technique limited by:
communicating pathologies
general or regional; all
Area; depth/technique limited by:
cardiac/circulatory disorders
regional; deep
Area; depth/technique limited by:
area of altered sensation
regional; deep
Area; depth/technique limited by:
impaired cognition/ communication
general or regional; all
What technique to palpate following layers?
1) superficial: epithelium & subcutaneous tissue
2) middle: subcutaneous tissue extensibility
3) deep: muscle, tendon, deep fascia
1) light touch, temperature, shear
2) skin rolling, superficial mobility
3) compression, muscle play
Traditional Massage
- static contact (possibly away from area of pain)
- to prepare patient
- Effleurage
- stroking
- Petrissage
- kneading and compression
- Precussion
- Vibration
Direction of Strokes
- direction of force optimized by body mechanics
- generally in line with forearm
- generally comes with weight shift
- parallel to muscle fibers (stroking, stripping) to lengthen
- perpendicular to muscle (strumming, bending) to break up adhesions
- circular
- distal to proximal. massage begins at proximal segment to assure venous flow.
- retrograde massage for edema reduction
Sequence of Strokes
- relaxing to start
- superficial to deep
- proximal segement before distal segments
- how to end depends on whats next in plan of care.
Pressure and Depth Varies
- palpated tissue
- body surfaces
- tissue type and person
- direction: proximal deep, distal light
- vary during massage: (start superficial > progressively deeper> end superficial)
- vary with stroke: effleurage, petrissage, friction
- moderate pressure essential for SNS effects
Duration
Local:
- impairment-outcome based:
- soft tissue release: 5-90seconds
- edema reduction: 5-30 minutes
- transverse friction massage 60-90sec total
General:
- 30-45 minutes or more
Effleurage
- slow stroking
- performed with: molded hands, finger/thumbs, knuckles, forearm, first webspace (2 hand, shingle, tree branches)
- purpose and expected outcomes?
Stroke Rate and Speed
- Vary with purpose:
- fast to invigorate (pre-sport)
- slow to relax or assess soft tissue
- Vary with stroke:
- effleurage 15/min
- petrissage 30-90/min
- friction 90-150/min
- Vary with direction
- slow for initial proximal stroke
- faster distal return
- Rhythmic to relax and communicate
Petrissage
(for edema reduction and muscle relaxation, increase circulation, decrease pain, decrease swelling)
- kneading, wringing, and rolling
- performed with: 2 hand, 1 hand, web spaces, pinch grasp, thumb (direct compression, 1-hand extremity kneading, J strokes)
